Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Complicated Alcohol Withdrawal-An Unintended Consequence of COVID-19 Lockdown.

AIM: To assess the impact of COVID-19-related lockdown in India on alcohol-dependent persons. METHOD: We examined the change in the incidence of severe alcohol withdrawal syndrome presenting to hospitals in the city of Bangalore. RESULTS: A changepoint analysis of the time series data (between 01.01.20 to 11.04.20) showed an increase in the average number of cases from 4 to 8 per day (likelihood ratio test: χ2 = 72, df = 2, P < 0.001). CONCLUSION: An unintended consequence of the lockdown was serious illness in some patients with alcohol use disorders.

Pellagra and Alcohol Dependence Syndrome: Findings From a Tertiary Care Addiction Treatment Centre in India.

AIM: To define the prevalence and clinical presentation of pellagra, a multi-systemic disease caused by the deficiency of niacin, in patients admitted to a tertiary addiction treatment centre in southern India, with alcohol dependence syndrome (ADS)-(ICD10). METHODS: Review of the health records of 2947 patients who received inpatient care for ADS between 2015 and 2017. RESULTS: Out of 2947, 31 (1%) were diagnosed with pellagra. Nearly two-thirds (64.5%) of those with pellagra were from a low-income group. Of the clinical-triad of pellagra, all patients had dermatitis, more than half (58%) had delirium, a minority (19%) had diarrhoea. Nearly two-thirds (61%) had presented in a complicated-withdrawal state. Associated conditions included peripheral neuropathy (32%); Wernicke's encephalopathy (26%); seizures (16%).Seventeen (54%) had BMI <18.5 kg/m2. Treatment was a high dose of parenteral vitamins including niacin (mean dose: 1500 mg/day) for an average of 7.5 days followed by oral multivitamin supplements. All had complete resolution of pellagrous symptoms by the end of the three weeks of inpatient care. CONCLUSIONS: Pellagra is an acute medical condition, frequently encountered in the context of alcohol dependence and poverty. It often presents with other disabling and life-threatening comorbidities like delirium tremens and Wernicke's encephalopathy. The classical triad of pellagra is only seen in a minority of cases. Thus a high index of suspicion is required lest pellagra may remain undiagnosed. Prompt identification and treatment with a high dose of niacin in combination with other vitamins result in complete recovery.

Cross cultural and global uses of a digital mental health app: results of focus groups with clinicians, patients and family members in India and the United States.

BACKGROUND: Despite significant advancements in healthcare technology, digital health solutions - especially those for serious mental illnesses - continue to fall short of their potential across both clinical practice and efficacy. The utility and impact of medicine, including digital medicine, hinges on relationships, trust, and engagement, particularly in the field of mental health. This paper details results from Phase 1 of a two-part study that seeks to engage people with schizophrenia, their family members, and clinicians in co-designing a digital mental health platform for use across different cultures and contexts in the United States and India. METHODS: Each site interviewed a mix of clinicians, patients, and their family members in focus groups (n = 20) of two to six participants. Open-ended questions and discussions inquired about their own smartphone use and, after a demonstration of the mindLAMP platform, specific feedback on the app's utility, design, and functionality. RESULTS: Our results based on thematic analysis indicate three common themes: increased use and interest in technology during coronavirus disease 2019 (COVID-19), concerns over how data are used and shared, and a desire for concurrent human interaction to support app engagement. CONCLUSION: People with schizophrenia, their family members, and clinicians are open to integrating technology into treatment to better understand their condition and help inform treatment. However, app engagement is dependent on technology that is complementary - not substitutive - of therapeutic care from a clinician.

Tolerance of transcranial direct current stimulation in psychiatric disorders: An analysis of 2000+ sessions.

Transcranial direct current stimulation (tDCS), a non-invasive, neuromodulatory technique, is being increasingly applied to several psychiatric disorders. In this study, we describe the side-effect profile of repeated tDCS sessions (N = 2005) that were administered to 171 patients (156 adults and 15 adolescents) with different psychiatric disorders [schizophrenia [N = 109], obsessive-compulsive disorder [N = 28], alcohol dependence syndrome [N = 13], mild cognitive impairment [N = 10], depression [N = 6], dementia [N = 2] and other disorders [N = 3]]. tDCS was administered at a constant current strength of 2 mA with additional ramp-up and ramp-down phase of 20 s each at the beginning and end of the session, respectively. Other tDCS protocol parameters were: schizophrenia and obsessive-compulsive disorder: 5-days of twice-daily 20-min sessions with an inter-session interval of 3-h; Mild cognitive impairment/dementia and alcohol dependence syndrome: at least 5-days of once-daily 20-min session; Depression: 10-days of once-daily 30 min session. At the end of each tDCS session, any adverse event observed by the administrator and/or reported by the patient was systematically assessed using a comprehensive questionnaire. The commonly reported adverse events during tDCS included burning sensations (16.2%), skin redness (12.3%), scalp pain (10.1%), itching (6.7%), and tingling (6.3%). Most of the adverse events were noted to be mild, transient and well-tolerated. In summary, our observations suggest that tDCS is a safe mode for therapeutic non-invasive neuromodulation in psychiatric disorders in adults as well as the adolescent population.

Packages of care for alcohol use disorders in low- and middle-income countries.

In the fourth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Vivek Benegal and colleagues discuss the treatment of alcohol use disorders.

Treatment of substance use disorders with co-occurring severe mental health disorders.

PURPOSE OF REVIEW: To provide an update of treatment for substance use in patients with co-occurring substance use disorders (SUD) and mental health disorders (dual diagnosis) with a focus on both pharmacological and psychosocial interventions. RECENT FINDINGS: A total of 1435 abstracts were identified, of which we selectively reviewed 43 for this narrative review. There is emerging evidence, both clinical and neurobiological, that clozapine is a more efficacious antipsychotic in treatment of individuals with schizophrenia and SUD. The use of depot atypical antipsychotic paliperidone palmitate in this population is also promising. Although valproate remains the treatment of choice in individuals with bipolar disorder and SUD, present evidence suggests that lithium and quetiapine may not be effective in this population. Naltrexone is the most effective anticraving agent in individuals with severe mental illness (SMI) and comorbid alcohol use disorders. The use of opioid substitution therapy in individuals with SMI and comorbid opioid use disorders is also associated with favorable outcomes. Varenicline shows promise in patients with SMI who smoke tobacco. Psychosocial interventions should be instituted early in the course of treatment. They should ideally be high intensity and based on established therapies used for SUD. SUMMARY: The paucity of systematic studies in individuals with co-occurring mental health disorders and SUD remains a concern, given the enormous burden that they pose. However, there are a number of studies which have evaluated interventions, both psychosocial and pharmacological, which show promise and can guide clinical practice. VIDEO ABSTRACT: http://links.lww.com/YCO/A49.

Case vignette-based evaluation of psychiatric blended training program of primary care doctors.

INTRODUCTION: The need to integrate psychiatry in primary care is increasingly recognized as the favorable strategy worldwide. The contribution of primary care doctors (PCDs) is extremely important toward it. However, majority PCDs find it difficult to diagnose and treat common psychiatric disorders. Many training programs developed for PCDs, with different methods employed for posttraining evaluation. One of such program is blended psychiatric training program developed at our center. AIM: Case vignette-based outcome evaluation of on-site section of blended psychiatric training of PCDs at the end of 2 weeks. MATERIALS AND METHODS: Two qualified psychiatrists designed the ten case vignettes after pilot use. Data were collected at baseline and at the end of 2 weeks on-site-training program. Major psychiatric diagnoses and treatments were covered. The responses to each vignette were evaluated with maximum marks 10 (5 each for diagnosis and treatment). RESULTS: The mean age of the 21 participants was 43.1 ± 7.3 years. The posttraining score (83.42 ± 10.38) was significant higher than the baseline score (42.4 ± 23.10). CONCLUSION: Blended program for training of PCDs in psychiatric disorders significantly improves their diagnostic and treatment capabilities.

The impact of depressive symptoms on the clinical presentation of Persistent Delusional Disorder.

BACKGROUND: Our aim was to investigate the influence of depressive symptoms on the clinical presentation of Persistent Delusional Disorder (PDD). METHODS: We have previously conducted a retrospective review of patients diagnosed with PDD (n = 455). We divided this sample into two groups according to the presence or absence of co-morbid depressive symptoms - a subsample of PDD with depressive co-morbidity (PDD + D; n = 187) and a subsample of PDD without depressive co-morbidity (PDD only; n = 268). RESULTS: PDD + D group had a significantly younger age at onset of PDD. The PDD + D group received significantly more antidepressants but had similar response and adherence rates. CONCLUSIONS: The presence of depressive symptoms in 41% of the study population did not appear to influence the clinical presentation or response to treatment.

Addiction severity and comorbidity among women with alcohol use disorders: A hospital-based study from India.

AIM: To examine the addiction severity, comorbid psychiatric disorder and their temporal relationship among women seeking treatment for Alcohol Use Disorders (AUDs). MATERIALS AND METHODS: The sample comprised of 35 women with AUDs, with or without psychiatric disorders, recruited from the outpatient and inpatient settings of a tertiary-care hospital. Their mean age was 38.51 years (S.D=7.42). Patients were assessed using Clinical Data Sheet (CDS), Mini-International Neuropsychiatric Interview (MINI), Structured Clinical Interview for DSM-IV Personality disorders (SCIDII), Addiction Severity Index (ASI)-Alcohol subscale and Fagerstrom Test for Nicotine Dependence (FTND). RESULTS: Findings of the study indicated that on average patients initiated alcohol use in their early twenties and developed dependence by the age of 29.66 years (S.D=7.60). The average duration of alcohol dependence was less than a decade before seeking treatment. The mean composite score on ASI was 0.71 (S.D=0.18) and on FTND was 5.16 (S.D=2.59), indicating a high level of alcohol and moderate level of nicotine dependence respectively. On MINI, 57.14% of the patients met the criteria for co-occurring Axis I psychiatric disorders such as major depression disorder and dysthymia. In the majority of the cases, comorbid Axis I disorders were secondary to AUDs. On SCID-II, 17% met the criteria for borderline personality disorder. CONCLUSION: Examining and understanding the substance use and clinical profile of patients with AUDs are crucial for planning intensity, settings and focus of treatment for women with AUDs.

Comparative outcome in patients with delirium tremens receiving care in emergency services only versus those receiving comprehensive inpatient care.

BACKGROUND: Delirium tremens (DT) is a medical emergency. Many cases are treated and discharged from emergency services (ES), after complete or partial resolution of delirium. Few receive comprehensive inpatient addiction treatment (CIAT) after the initial emergency management. OBJECTIVE: The objective of this study was to compare 6-month outcomes of treatment in alcohol-dependence syndrome (ADS) patients presenting with DT receiving either only emergency care or emergency care along with CIAT. MATERIALS AND METHODS: In this prospective observational study, all patients of ADS presenting in DT over a 1-year period were followed up for 6 months. Patients who received care only in the emergency services (ES) (111) were compared with patients who received ES followed by CIAT (90). Primary followup measure was regular followup (RFU) at outpatient department, and patients not presenting for RFU received telephonic followup (TFU). Alcohol use status was monitored at 6 months, as per Feuerlein and Küfner criteria. RESULTS: Patients who received both ES and CIAT had better RFU compared to patients treated in the ES alone at 6 months (71/90 vs. 17/111, respectively, P < 0.005). CIAT also resulted in better combined follow-up (RFU and TFU) (85/90 vs. 60/111, respectively, P < 0.005). Compared to ES treatment group alone, ES plus CIAT group had fewer relapses (41/85 vs. 42/60, respectively, P < 0.05). The most common reason for direct discharge from ES was nonavailability of beds for inpatient treatment. CONCLUSIONS: Merely emergency treatment of ADS patients presenting with DT does not provide satisfactory treatment outcome with respect to alcohol use. ES treatment followed by CIAT ensures better outcome in the form of fewer relapses and better follow up.

Risperidone versus olanzapine in the acute treatment of Persistent Delusional Disorder: A retrospective analysis.

There is a dearth of prospective trials studying treatment response in Persistent Delusional Disorder (PDD) to guide clinical practice. Available retrospective data indicate good response to second-generation antipsychotics (SGAs). We selected the data of patients prescribed either olanzapine or risperidone from a retrospective chart review of PDD (n=455) at our centre. We compared the two groups olanzapine (n =86) versus risperidone (n =280) on dose, drug adherence, response and adverse effects. The two groups were comparable on socio-demographic and clinical characteristics of PDD. There was no statistically significant difference between the two groups on adherence (>80%) and response to treatment (>52% good response). Olanzapine was effective at lower mean chlorpromazine equivalents than risperidone. Logistic regression analysis identified shorter mean duration of illness, good adherence and absence of substance dependence as predictors of good response to both drugs. Our study indicates that acute PDD responds well to treatment with both risperidone and olanzapine, provided adherence can be ensured. In the absence of specific treatment guidelines and randomized controlled trials for PDD, our analysis reaffirms the efficacy of SGAs.

Dissociative and conversion disorders: defining boundaries.

PURPOSE OF REVIEW: Although dissociative disorders have been described and diagnosed for some time, their aetiology, pathogenesis, phenomenology and management continues to arouse debate. It is only in recent times that researchers have made some progress by integrating trauma related theories with more contemporary cognitive theories and neurobiology. RECENT FINDINGS: Dissociation as a phenomenon is reported to occur in a variety of disorders. This widespread occurrence has contributed to a better understanding of dissociation. An expansion of this concept may have contributed to the loss of its original significance. Recent studies in the field of dissociation that pertain to its aetiology, pathophysiology, neurobiology and management are critically reviewed. SUMMARY: Dissociative disorder is conceptually a difficult disorder to study. Apart from exposure to trauma, certain primary personality attributes may contribute to the propensity to develop dissociative disorder. Recent advances in functional neuroimaging facilitated by enhanced knowledge in the neural representation of body state have helped to improve our understanding of dissociation. There is confusion over the use of various terms such as sexual abuse and physical abuse in explaining causality. Current classificatory systems have not been found suitable when applied across cultures. In spite of all of these limitations, there has been recent progress toward a better understanding of dissociative disorders.

Clinical Presentation and Course of Persistent Delusional Disorder: Data From a Tertiary Care Center in India.

OBJECTIVE: Despite its long history as a psychiatric diagnosis, little is known about the sociodemographic and clinical profile of persistent delusional disorder (PDD) or its subtypes, treatment response, and outcomes, particularly in India. We examined the clinical characteristics and course of PDD in patients presenting to a tertiary neuropsychiatry center in India. METHOD: A retrospective chart review of patients diagnosed with PDD (ICD-10) between January 2000 and May 2014 was conducted. Sociodemographic and clinical data including age at onset, total duration of the illness, clinical symptoms and treatment, hospitalizations, occupational functioning, and follow-up were extracted from the files. The study was approved by the institute ethics committee. RESULTS: The sample (N = 455) consisted of 236 men and 219 women. The mean age at onset was 32.36 ± 10.47 years. The most common delusion was infidelity (n = 203, 44.6%) followed by persecution (n = 149, 32.7%). Hallucinations were present in 78 (17.1%), depressive symptoms in 187 (41.1%), and comorbid substance dependence in 61 (13.4%) subjects; 141 subjects (31.0%) had a family history of mental illness. Follow-up data were available for 308 subjects, of whom 285 (92.5%) reported good compliance with medication. Of the subjects, 163 (52.9%) showed a good response to treatment. The diagnosis of PDD remained unchanged in 274 of 308 subjects (88.9%). CONCLUSION: In our center, PDD appears to be uncommon and has a near-equal gender representation. Infidelity was the most common delusion, which is in contrast to the reported literature. The diagnosis of PDD appears to be stable with good response to atypical antipsychotics if compliance can be ensured.